{"data":{"id":"us-tx/tex.-insurance-code-1458.001","jurisdiction":"us-tx","citation":"Tex. Insurance Code § 1458.001","heading":"GENERAL DEFINITIONS.","body":"In this chapter:\n(1) \"Affiliate\" means a person who, directly or indirectly through one or more intermediaries, controls, is controlled by, or is under common control with another person.\n(1-a) \"Anti-steering clause\" means a provision in a provider network contract that restricts the ability of a general contracting entity to encourage an enrollee to obtain a health care service from a competitor of the provider, including offering incentives to encourage enrollees to use specific providers.\n(1-b) \"Anti-tiering clause\" means a provision in a provider network contract that:\n(A) restricts the ability of a general contracting entity to introduce or modify a tiered network plan or assign providers into tiers; or\n(B) requires a general contracting entity to place all members of a provider in the same tier of a tiered network plan.\n(2) \"Contracting entity\" means a person who:\n(A) enters into a direct contract with a provider for the delivery of health care services to covered individuals; and\n(B) in the ordinary course of business establishes a provider network or networks for access by another party.\n(3) \"Covered individual\" means an individual who is covered under a health benefit plan.\n(4) \"Express authority\" means a provider's consent that is obtained through separate signature lines for each line of business.\n(4-a) \"Gag clause\" means a provision in a provider network contract that restricts the ability of a general contracting entity or provider to disclose:\n(A) price or quality information, including the allowed amount, negotiated rates or discounts, fees for services, or other claim-related financial obligations included in the contract, to a governmental entity as authorized by law or its contractors or agents, an enrollee, a treating provider of an enrollee, a plan sponsor, or potential eligible enrollees and plan sponsors; or\n(B) out-of-pocket costs to an enrollee.\n(4-b) \"General contracting entity\" means a person who enters into a direct contract with a provider for the delivery of health care services to covered individuals regardless of whether the person, in the ordinary course of business, establishes a provider network for access by another party. The term does not include a health care provider or facility unless the provider or facility is entering into the contract in the provider's or facility's role as a health benefit plan.\n(5) \"Health care services\" means services provided for the diagnosis, prevention, treatment, or cure of a health condition, illness, injury, or disease.\n(5-a) \"Most favored nation clause\" means a provision in a provider network contract that:\n(A) prohibits or grants an option to prohibit:\n(i) a provider from contracting with another general contracting entity to provide health care services at a lower rate; or\n(ii) a general contracting entity from contracting with another provider to provide health care services at a higher rate;\n(B) requires or grants an option to require:\n(i) a provider to accept a lower rate for health care services if the provider agrees with another general contracting entity to accept a lower rate for the services; or\n(ii) a general contracting entity to pay a higher rate for health care services if the entity agrees with another provider to pay a higher rate for the services;\n(C) requires or grants an option to require termination or renegotiation of an existing provider network contract if:\n(i) a provider agrees with another general contracting entity to accept a lower rate for providing health care services; or\n(ii) a general contracting entity agrees with a provider to pay a higher rate for health care services; or\n(D) requires:\n(i) a provider to disclose the provider's contractual reimbursement rates with other general contracting entities; or\n(ii) a general contracting entity to disclose the general contracting entity's contractual reimbursement rates with other providers.\n(6) \"Person\" has the meaning assigned by Section 823.002.\n(7)(A) \"Provider\" means:\n(i) an advanced practice nurse;\n(ii) an optometrist;\n(iii) a therapeutic optometrist;\n(iv) a physician;\n(v) a physician assistant;\n(vi) a professional association composed solely of physicians, optometrists, or therapeutic optometrists;\n(vii) a single legal entity authorized to practice medicine owned by two or more physicians;\n(viii) a nonprofit health corporation certified by the Texas Medical Board under Chapter 162, Occupations Code;\n(ix) a partnership composed solely of physicians, optometrists, or therapeutic optometrists;\n(x) a physician-hospital organization that acts exclusively as an administrator for a provider to facilitate the provider's participation in health care contracts; or\n(xi) an institution that is licensed under Chapter 241, Health and Safety Code.\n(B) \"Provider\" does not include a physician-hospital organization that leases or rents the physician-hospital organization's network to another party.\n(8) \"Provider network contract\" means a contract between a contracting entity and a provider for the delivery of, and payment for, health care services to a covered individual.\nAdded by Acts 2013, 83rd Leg., R.S., Ch. 197 (S.B. 822), Sec. 1, eff. September 1, 2013.\nAmended by:\nActs 2023, 88th Leg., R.S., Ch. 639 (H.B. 711), Sec. 1, eff. June 12, 2023.","path":["INSURANCE CODE","TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES","SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS","CHAPTER 1458. PROVIDER NETWORK CONTRACT ARRANGEMENTS","SUBCHAPTER A. GENERAL PROVISIONS"],"source_url":"https://statutes.capitol.texas.gov/Docs/IN/htm/IN.1458.htm#1458.001","current_through":"89th 2nd Called Legislative Session, 2025","vintage":"","retrieved_at":"2026-08-27T01:47:21Z","sha256":"1195ad564064986c5ce246a1728532bc82734b6f74a07b1cf1e2275ef998fa3e","source_id":"us-tx","stale":false,"prev":"us-tx/tex.-insurance-code-1457.002","next":"us-tx/tex.-insurance-code-1458.002"},"notice":"GroundRules: Original legal text. Not legal advice."}